Provider Demographics
NPI:1316244627
Name:JOHNSON, MICHAEL ANTHONY (PHD, HSPP)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6208 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1927
Mailing Address - Country:US
Mailing Address - Phone:317-251-9777
Mailing Address - Fax:317-251-9798
Practice Address - Street 1:6208 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1927
Practice Address - Country:US
Practice Address - Phone:317-251-9777
Practice Address - Fax:317-251-9798
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042500A103TA0400X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent